Selective feticide in twin pregnancies with very early preterm premature rupture of membranes

Selective feticide in dichorionic diamniotic (DCDA) twins complicated with previable premature rupture of membrane before 24 weeks may be a safe therapeutic alternative to ongoing pregnancy

BACKGROUND

To date, there are no clinical guidelines for dichorionic diamniotic (DCDA) twins complicated with previable premature rupture of membrane (PV-ROM) before 24 weeks of gestation. The typical management options including expectant management and/or pregnant termination, induce the risks of fetal mortality and morbidity.

OBJECTIVE

To explore the feasibility selective feticide in DCDA twins complicated with PV-ROM.

STUDY DESIGN

A Retrospective cohort study, enrolling 28 DCDA twins suffering from PV-ROM in a tertiary medical center from Jan 01 2012 to Jan 01 2022. The obstetric outcome was compared between selective feticide group and expectant management group.

RESULTS

There were 12 cases managed expectantly and 16 underwent selective feticide. More cases suffered from oligohydramnios in expectant management group compared to selective feticide group (P = 0.008). Among 13 cases with ROM of upper sac, the mean gestational age at delivery was (33.9 ± 4.9) weeks in the selective feticide group, which was significantly higher than that in the expectant management (P = 0.038). Five fetuses (83.3%) with selective feticide delivered after 32 weeks, whereas only one (14.3%) case in expectant management group (P = 0.029). However, in the subgroup with ROM of lower sac, no significant difference of the mean gestation age at delivery between groups and none of cases delivered after 32 weeks.

CONCLUSION

There was a trend towards an increase in latency interval in DCDA twins with PV-ROM following selective feticide, compared to that with expectant management. Furthermore, selective feticide in cases with PV-ROM of upper sac has a favorable outcome.

Longest Survival of Expectantly Managed Twin Gestation Complicated by Previable Preterm Premature Rupture of Membranes at 13 Weeks' Gestation

Previable preterm premature rupture of membranes (PV-PPROM) is defined as rupture of membranes prior to 24 weeks and is a rare phenomenon with an estimated prevalence of 0.5% of all pregnancies. Given that this phenomenon is even more rare in patients with dichorionic diamniotic (DCDA) twin pregnancies, there is no clear consensus in the literature on outcomes and management of DCDA PV-PPROM due to the scarcity of reports. We report a case of a rare successful prolongation of first trimester DCDA PV-PPROM pregnancy with rupture of the amniotic sac of one twin with survival of both twins without major complications. A 20-year-old female gravida 1 para 0 at about 13 weeks and three days presented with vaginal watery discharge mixed with vaginal bleeding. Abdominal ultrasound revealed a live twin dichorionic diamniotic (DCDA) spontaneous intrauterine gestation and a significantly low amniotic fluid volume involving fetus A. At 23 weeks gestational age, she experienced increased leaking of clear fluid, and she was admitted to the hospital for continuous monitoring with daily non-stress tests (NST), and ultrasounds every four weeks, and received antibiotics, betamethasone, and magnesium. Preterm labor occurred at 30w1d, and a primary low transverse cesarean section was performed on the 114th day after PPROM. Though, twin A required prolonged hospitalization both twins recovered and progressed well without complications. To the best of our knowledge, this is the longest case of successful expectant management of both twins with PV-PPROM yet reported.

Pregnancy and birth outcomes of multiple gestations with PPROM occurred within 24 h after fetal reduction: A case series

OBJECTIVE

The study aims to analyze the pregnancy outcomes of multiple gestations with preterm premature rupture of membranes (PPROM) that occurred within 24 h after fetal reduction with potassium chloride (KCL).

MATERIALS AND METHODS

We identified and evaluated the outcomes of 16 retrospectively recorded multigestational pregnancies that met the inclusion criteria between 2006 and 2016, from the Obstetrics Department of Shandong Provincial Hospital. A total of 16 patients carrying twins or higher order multiple gestations experienced PPROM within 24 h after fetal reduction, and all of them received expectant management after understanding the relevant risks. The maternal and neonatal records were retrospectively collected and reviewed. Every surviving child was followed up to at least 2 years old.

RESULT

Of the 16 cases, 12 cases (75%) ended in successful pregnancy, resulting in the delivery of at least 1 child surviving from a multiple gestational pregnancy. All cases of successful pregnancies were either term (≥37 weeks) or near-term (36⁺⁵ weeks) at delivery. And of those 20 infants delivered, only 3 were low birth weight infants (<2500g) (15%), None of the 16 women had fever, or other clinical symptoms and signs of chorioamnionitis during hospital stay. Postnatal follow-up of the surviving babies showed no obvious sequelae thus far. No newborn baby had neonatal complications, or needed to be transferred to neonatal intensive care unit.

CONCLUSION

Overall, our data demonstrate that dichorionic diamniotic (DCDA) twins or higher-order gestations who experienced PPROM of the reduced fetus within 24 h after selective reduction with KCL had relatively good outcomes with expectant management alone.

Perinatal Outcome of Twin Pregnancies Complicated by Rupture of Membranes at 13-20 Weeks: Is Selective Termination an Appropriate Management Option?

OBJECTIVE

 To evaluate the outcome of twin pregnancies that were complicated by rupture of membranes at 13-20 weeks of gestation and were managed by expectant management or by selective termination.

METHODS

 A retrospective cohort study of all bichorionic twin pregnancies that were referred to three fetal medicine units between 2001 and 2016, due to rupture of membranes of one sac at 13-20 weeks of gestation. Women without clinical signs of infection who opted for expectant management or selective termination were included.

RESULTS

 20 patients met the inclusion criteria. 7 of them were managed expectantly and 13 underwent selective termination. In the expectant management group there was one case of fetal demise and two cases of neonatal death, resulting in a survival rate of 79 %. The median gestational age at delivery was 30 weeks. 3 neonates suffered from prematurity-related complications and 2 suffered from oligohydramnios-related orthopedic complications. Following selective termination the survival rate was 50 % (all fetuses that were not reduced), the median gestational age at delivery was 39 weeks, and the neonatal outcome was favorable. The maternal outcome was favorable in both groups.

CONCLUSION

 Selective termination in twin pregnancies complicated by rupture of membranes at 13-20 weeks has a favorable outcome and should be offered.

Outcomes of Selective Reduction of DCDA Twins Complicated by PV-PROM Compared with Expectant Management: A Case Series and Review of the Literature

OBJECTIVE

To report the outcomes of selective reduction (SR) in dichorionic twins complicated by pre-viable, premature rupture of membranes (PV-PROM).

METHODS

Retrospective case series. Ultrasound database was searched for cases of dichorionic twin pregnancy with PV-PROM, either managed conservatively or with SR. Chart reviews were done for these cases. Simple descriptive statistics were used where appropriate.

RESULTS

Twenty-two cases of expectantly managed dichorionic twins complicated by PV-PROM with delivery information were available for analysis. Mean GA at PV-PROM was 20.6 weeks, mean GA of delivery was 27.6 weeks, and the mean latency was 39.6 days. There were five cases of SR following PV-PROM in dichorionic twin pregnancies. Mean GA of PV-PROM was 17.0 weeks. Average time from PV-PROM to procedure was 2.5 weeks. Mean GA of delivery of the surviving fetus was 32.6 weeks (P = 0.20) with mean latency of 108 days (P = 0.06). Twelve additional cases have been published and are summarized along with our five cases.

CONCLUSION

There was a trend towards an increase in latency interval between cases of PV-PROM managed by SR and expectant management in our institution. When combined with the existing literature data, there may be an improvement in latency.

Management of very early preterm premature rupture of membranes (PPROM) in twin pregnancies by selective feticide

Aim:

To assess the efficacy of selective termination in improving pregnancy outcome in very early preterm premature rupture of membranes (PPROM) in twin pregnancies.

Methods:

A total of six dichorionic twin intracytoplasmic sperm injection (ICSI) pregnancies complicated with very early PPROM between 17+5 and 19+3 gestational weeks were admitted to our hospital and were managed by selective termination of the member with ruptured membranes and followed up. Two cases were twins reduced from triplets at our unit (33%). The fetuses with ruptured membranes were subjected to feticide by intra-cardiac injection of potassium chloride after a mean of 3.5 days following PPROM.

Results:

The overall PPROM-delivery/miscarriage time-interval was 80 days using the proposed management scheme. Two cases ended with total pregnancy loss at 21+ and 23+ weeks, respectively. Four cases progressed successfully beyond 29 weeks, reaching an average of 35+5 days.

Conclusions:

The handling of these six twin PPROM cases as described produced a healthy baby to take home in four instances, resulting in a success rate of 67%, whereas the implementation of a more conservative approach using antibiotics and steroids is expected to lead to a survival rate of around 15% and a handicap rate up to 50%.

Outcome of Twin Pregnancies Complicated By Early Second Trimester Rupture of Membranes in One Sac

The aim of this study was to present the outcome of bichorionic twin pregnancies complicated by early second trimester rupture of membranes in one sac. Data regarding all cases of ruptured membranes at 13–20 weeks in bichorionic twin pregnancies were collected retrospectively from three fetal medicine units. Patients who have chosen to terminate the pregnancy were excluded from the study. Between January 2003 and July 2009, nine patients met inclusion criteria. Three out of nine couples decided on expectant management, and six preferred selective feticide. With expectant management one fetus died in utero and take home baby rate was 83% (5 of 6 fetuses), delivered at 27–32 weeks. When selective termination was performed, all non-reduced fetuses were born alive at 33–40 weeks. Two survivors of rupture of membranes had limb contractures, none had lung hypoplasia. One patient had clinical signs of amnionitis, which was ruled out later on pathological examination. Her post partum course was uncomplicated. Our data suggest that rupture of membranes in one sac of bichorionic twins at 13–20 weeks has favorable prognosis whether an intervention is preformed or not. Nonetheless, selective termination may have an advantage over expectant management, since gestational age at delivery was higher when selective termination was performed.

Diagnosis and management of obstetrical complications unique to multiple gestations

Obstetrical complications unique to multiple gestations pose a number of unique challenges. The presence of more than one fetus complicates the diagnosis and management of a pregnancy when one fetus has a structural or chromosomal abnormality, intrauterine demise, preterm premature rupture of the membranes, or delivers prematurely. Similarly, the diagnosis and management of monoamniotic twins and conjoined twins is challenging. These obstetrical complications that are unique to multiple gestations require thorough counseling of the expectant parents, as well as care by physicians with expertise in the management of multiple gestations.

Obstetric outcome after fetal reduction to singleton pregnancies

OBJECTIVE

To study the outcome after fetal reduction or selective termination to singleton pregnancies for various indications.

METHODS

Fetal reduction or selective feticide to singleton pregnancies was performed in 80 multiple gestations (congenital malformations, 17 cases; high-risk obstetric conditions, 25 cases; or social/psychological indications, 38 cases).

RESULTS

The overall pregnancy loss rate was 10%; however, pregnancy failure was significantly higher in selective reductions performed for preterm prelabor rupture of membranes (PPROM) (4/8) compared with monochorionic twin and bad obstetric history. Fetal reduction to singletons for psychological reasons resulted in a pregnancy wastage of 5.3% (2/38). Procedures performed at < or =14 weeks showed a significantly lower fetal loss rate (2/61; 3.3%), a higher mean gestational age at delivery (38.3+/-2.2 weeks), and a decreased prematurity rate (p< or =0.001). The number of reduced fetuses, prenatal diagnosis by chorionic villus sampling before the reduction and maternal age did not interfere with pregnancy outcome.

CONCLUSION

Fetal reduction to singleton pregnancies has a favorable outcome, especially when performed before 14 weeks of gestation.